Healthcare Provider Details

I. General information

NPI: 1407951544
Provider Name (Legal Business Name): BRYAN J KINGSRITER LICSW,LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6550 YORK AVE S SUITE 503
EDINA MN
55435-2347
US

IV. Provider business mailing address

1236 VICTORIA ST N
SAINT PAUL MN
55117-4033
US

V. Phone/Fax

Practice location:
  • Phone: 952-929-3103
  • Fax:
Mailing address:
  • Phone: 651-647-1900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12105
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number106
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: